2019-01-16_stephaniem_English Application (1).docx

Employment Application

Disclosure Statement:

Home Care Assistance is an equal-opportunity employer and is committed to providing a workplace free from harassment or discrimination. All employment decisions are made without regard to race, skin color, religion, gender, national origin, ancestry, sex, age, handicap, marital status, sexual orientation, physical or mental disability, pregnancy, military status, or any other basis prohibited by law.

Today’s Date: _______________________________________

First Name: ______________________________ Last Name: ______________________________

Street Address: ____________________________________________________________________

City: ____________________________ Province: ___________ Postal Code: _________________

Home Phone: __________________________ Cell Phone: _________________________________

Email Address: ______________________________________________________________________

Social Insurance Number: ____________________ Expiration Date: _________________

Are you legally eligible for employment in Canada? ___________

Driver’s License Number: _________________________ Car Insurance:     Yes      No

IMPORTANT: All caregiver positions at Home Care Assistance are considered TEMPORARY (seasonal) due to the frail condition of our elderly clients. Continued employment is not guaranteed for any caregiver as all employment is at-will, indefinite and not for any specific period of time.

I understand and accept this condition of employment: _________________________________________

(Signature of Applicant)
What are you applying for? (Please check off all applicable options)

Day Shift: 		Evening Shift:			Overnight Shift: 		Live-In Shift:

What are your availabilities at the moment? (Days of the week/Times) __________________________________________________________________________________________________________________________________________________________________________

If hired, on what date can you start work? ______________________________________________

Emergency Contact Information

Name: ___________________________________________________________________

Relationship: _____________________________________________________________

Home Number: ___________________________________________________________

Cellphone Number: _______________________________________________________

Name: ___________________________________________________________________

Relationship: _____________________________________________________________

Home Number: ___________________________________________________________

Cellphone Number: _______________________________________________________

Allergies

Please list any allergies that you have:

__________________________________________________________________________________________________________________________________________________________

RECORD OF PREVIOUS EMPLOYMENT (If you have filled out this section online already, please omit)

May we contact the employers listed above?      Yes           No

If no, please indicate which one: ________________________________________________________________

Have you ever been terminated or asked to resign from any job?      Yes           No

If yes, please explain why:

__________________________________________________________________________________________________________________________________________________________________________________________

REFERENCES (If you have filled out this section online already, please omit)

List below 2 people not related to you whom you have known for at least one year and who can provide information about your skills and experience

1) Name:  ___________________________________________________________________________

Address: ____________________________________________________________________________

Phone:  _______________________________ Relationship: _________________________________

Number of years acquainted: _________________________________________________________

Is this a   PERSONAL   or   BUSINESS    reference? (Circle one)

2) Name:  ___________________________________________________________________________

Address: ____________________________________________________________________________

Phone:  _______________________________ Relationship: _________________________________

Number of years acquainted: _________________________________________________________

Is this a   PERSONAL   or   BUSINESS    reference? (Circle one)

EDUCATION (If you have filled out this section online already, please omit)

High School

School Name: _____________________________________________________________

Diploma/Degree: __________________________________________________________

Location: __________________________________________________________________

College/University

School Name: _____________________________________________________________

Diploma/Degree: __________________________________________________________

Location: __________________________________________________________________

Vocational School

School Name: _____________________________________________________________

Diploma/Degree: __________________________________________________________

Location: __________________________________________________________________

EXPERIENCE – ELDERCARE/HOMECARE

Please check off the job(s) you are applying for:

Companion

PAB   Received on: _________________________

PSW  Received on: _________________________

LPN   License Number: _________________________ Expiration Date: _____________________________

List all professional licenses or certificates that you have: __________________________________________________________________________________________________________________________________________________________________________

This job may require you to transfer up to 75 pounds of dead weight from/to a bed, commode, couch, wheelchair, etc.… Are you able to perform this task?      Yes          No

Please check off the job skills you have experience in and will perform:

Please check off the following conditions/diagnosis with which you have experience and job skills to care for a patient:

Please check off the job responsibilities you are comfortable doing in addition to Eldercare:

Please check off the Home Medical Equipment you have experience with:

Meal Preparation

Based on your level of comfort, which of the meals portrayed below are you comfortable preparing for your clients? Please place a  where applicable.

Breakfast:

Lunch:

Dinner:

AUTHORIZATION TO RELEASE INFORMATION

It is the policy of Home Care Assistance to conduct reference checks for employment candidates. Your signature below indicates your agreement with and acknowledgment of the following

As an applicant for employment with Home Care Assistance, I authorize my current and past employers and current and past work associates to release to Home Care Assistance any reference and employment information, including but not limited to performance evaluations and attendance records and work-related personal characteristics (e.g. my character, dependability, honesty, integrity, interpersonal skills, etc.)

Home Care Assistance will maintain reference information in strictest confidence and solely for the purposes of the recruitment for which I have applied.

A photocopy of this signed Authorization is to be considered valid as an original.

I have carefully read and understand all of the provisions above and have voluntarily agreed to sign this authorization.

__________________________________                   _________________________________

(Printed Name)                                                                                           (Signature)

_________________________________

(Date)

WORKPLACE SAFETY RULES

Your safety is the constant concern of Home Care Assistance. Every precaution has been taken to provide a safe workplace. Common sense and a personal interest in safety are still the greatest guarantees of your safety at work, on the road, and at home.

The cooperation of every Caregiver is necessary to make Home Care Assistance a safe place in which to work. Help yourself and others by reporting unsafe conditions or hazards immediately to the office. Give earnest consideration to the rules of safety presented to you by signs, discussions with your Supervisor, posted department rules, and regulations published in the safety booklet. Always think of safety as you perform your job, or as you learn a new one.

ACCIDENT REPORTING

Ant injury at work, no matter how small, must be reported immediately to your Supervisor and receive first aid attention. Serious conditions often arise from small injuries if they are not cared for at once.

SPECIFIC SAFETY RULES AND GUIDELINES

To ensure your safety, and that of your co-workers, please observe and obey the following rules and guidelines:

Observe and practice the safety procedures established for the job

In case of sickness or injury, no matter how slight, report at once to your Supervisor. In no case should a Caregiver treat his/her own or someone else’s injuries or attempt to remove foreign particles from the eye.

In case of injury resulting in possible fracture to legs, back, or nick, or any accident resulting in an unconscious condition, or a severe head injury, the Caregiver is not to be moved until authorized personnel have given medical attention.

All caregivers must use seat belts and shoulder restraints whenever they operate a vehicle on company business. The driver is responsible for seeing that all the passengers in the front and rear seats are buckled up.

Never distract the attention of another Caregiver, as you might cause him or her to be injured

Where required, you must wear protective equipment, such as goggles, safety glasses, masks, gloves, hair nets, etc...

Do not tamper with electric controls or switches

Do not operate machines or equipment until you have been properly instructed and authorized to do so by your Supervisor

Do not engage in such other practices as may be inconsistent with ordinary and reasonable common-sense safety rules

Lift properly – use your legs, not your back. For heavier loads, ask for assistance

Do not throw objects

Wear hard sole shoes and appropriate clothing. Shorts or mini dresses are not permitted

SAFETY CHECKLIST

It’s every Caregiver’s responsibility to be on the lookout for possible hazards. If you spot one of the conditions on the following list – or any other possible hazardous situation – report it to your Supervisor immediately:

Slippery floors and walkways

Tripping hazards

Poorly lighted stairs

Loose handrails or guard rails

Loose or broken windows

Open or broken windows

Unlocked doors and gates

Electrical equipment left operating

Open doors on electrical panels

Leaks of steam, water, oil, etc.…

Blocked fire extinguishers, hose sprinkler heads

Evidence of any equipment running hot or overheating

Roof leaks

ACKNOWLEDGMENT

I have received a copy of the Workplace Safety Rules and understand that it sets forth the terms and conditions of my employment as well as the duties, responsibilities, and obligation of my employment with Home Care Assistance.

SMOKING, DRUG AND ALCOHOL POLICY

For purposes of this policy the following terms shall have the following meanings:

Smoking is defined as the inhaling, exhaling, burning or carrying a lighted cigarette, cigar, pipe, or other lighted smoking equipment for any product containing tobacco.   

Tobacco products are defined as any product containing tobacco, the prepared leaves of plants of the nicotine family, including, but not limited to, cigarettes, loose tobacco, cigars, snuff, chewing tobacco, or any other preparation of tobacco.

The Home Care Assistance smoking policy is:

Smoking is prohibited inside all client residences, Home Care Assistance buildings and company-owned passenger vehicles

Smoking is prohibited in any outdoor area within give (5) feet of any main exit or entrance of all client residences and Home Care Assistance buildings

Managers and supervisors are responsible for informing all Home Care Assistance caregivers of the “Smoking Policy” and for administering appropriate disciplinary action for continual and/or flagrant violations of this policy

Alcohol means any alcohol or alcoholic beverage.

Drug means any drug, other than alcohol, including but not limited to illegal drugs and prescription or over-the-counter drugs

Illegal Drug means any controlled substance, drug, narcotic or immediate precursor which may subject an individual to criminal penalties, or a legal drug which has not been legally obtained or is being used by an individual for whom it was not prescribed, or is not being used in a manner, combination or quantity for which it was manufactured, prescribed, or intended.

Legal Drug means any over-the-counter drug or prescription drug which has been legally obtained and is being used in the manner, combination and quantity for which it was manufacture, prescribed, or intended.

Under the Influence means that a drug or alcohol is present in the caregiver’s bodily system.

Each Home Care Assistance caregiver commits and urges all other caregivers to commit, that while performing services for Home Care Assistance clients they:

Shall not in any way be impaired because of being under the influence of alcohol or a drug

Shall not possess, consume, or be under the influence of alcohol and/or an illegal drug

Shall not sell, offer, or provide alcohol or a drug to another person

I HAVE READ ALL THE ABOVE, ASKED ALL THE QUESTIONS I DESIRED, AND UNDERSTAND AND AGREE.

__________________________________                   _________________________________

(Printed Name)                                                                                           (Signature)

_________________________________

(Date)

FRANCHISEE EMPLOYEE ACKNOWLEDGMENT FORM

I, the undersigned, am an employee of Home Care Assistance (Montreal) Inc. (the “Franchisee”).

I understand and acknowledge that Franchisee is a franchisee of HCA Franchise Corporation d/b/a Home Care Assistance Group Inc. (“HCA”). I further understand and acknowledge that, regardless of the relationship between HCA and Franchisee. I am and will be an employee of Franchisee. I am not and will not be an employee of HCA.

I will look solely to Franchisee for all of my compensation and benefits. I understand and agree that I will not be eligible to receive any kind of compensation or benefits from HCA and will not be eligible to participate in any of HCA’s employee benefit plans or programs. I further understand and acknowledge that all decisions regarding discipline or the termination of my employment with Franchisee shall be made by Franchisee, not HCA.

__________________________________                   _________________________________

(Printed Name)                                                                                           (Signature)

_________________________________

(Date)

CAREGIVER / AGENCY AGREEMENT

This Caregiver/Agency Agreement (this “Agreement”) is made by and between Home Care Assistance Inc., herein represented by ____________________________________, duly authorized for the purposes hereof as he/she so declares (“HCA”) and ______________________________________________________, domiciled and residing at 
______________________________________________________ (the “Caregiver”) (collectively the “Parties”);

Terms of the Agreement

The Caregiver is hereby retained by HCA to provide caregiver and support services to clients of HCA on a scheduled basis (the “Services”). Services shall be performed in accordance with a schedule prepared by HCA and approved by the Caregiver.

HCA agrees to pay the Caregiver $______              per hour for Services rendered. Caregiver shall receive the wages herein prescribed on a biweekly basis. Caregiver shall not incur or charge HCA any other fees or expenses without the prior authorization of HCA.

This Agreement shall commence on the date as mutually agreed upon by the parties (the “Effective Date”).

No Solicitation

Caregiver shall not, during the Agreement and for a period of THREE (3) years immediately following termination of this Agreement pursuant to section 5 thereof, either directly or indirectly, call on, solicit, or take away, or attempt to call on, solicit, or take away, any of the customers or clients of HCA on whom Caregiver called or became acquainted with during the terms of this Agreement, either for their own benefit, or for the benefit of any other person, firm, corporation or organization.

If Caregiver desires to work with a particular client other than in accordance with this Agreement at any time within THREE (3) years following the conclusion of Caregiver’s services for said client, Caregiver shall pay HCA a fee of FIVE THOUSAND DOLLARS ($5,000.00) prior to commencing any services for said client in consideration of HCA introducing the client to the Caregiver.

Absences

The Caregiver must inform a representative of HCA of any planned absence at least TWO (2) weeks in advance. Once the Caregiver has been scheduled for services, permission for any absence for non-medical reasons is at the sole discretion of HCA.

Client Interaction
(a) Under no circumstances is Caregiver allowed to speak directly or indirectly to the client of a representative thereof regarding matters of pay. If the client attempts to solicit the Caregiver, the Caregiver must inform HCA of the interaction within TWENTY-FOUR (24) hours. Caregiver must never discuss personal concerns with the client and must report any such concerns to a representative of HCA. Caregiver may not take money directly from the client. Where cash is required, Caregiver must obtain said cash directly from HCA and provide HCA with a receipt for same.

Termination

The Agreement may be terminated without any compensation, payment, or severance whatsoever on the happening of any of the following events:

The death of the Caregiver;

By the Caregiver providing FIFTEEN (15) day written notice;

By HCA upon a written notice;

In the event the Caregiver fails to provide the FIFTEEN (15) day written notice as provided in Section 5 a) ii) hereinabove, HCA reserves the right to deduct the sum of THIRTY-FIVE DOLLARS ($35.00) from the Caregiver’s wages as compensation to HCA for payment of the Caregiver’s Background Check;

Indemnity

In the event of any fraud, misrepresentation, or negligent act by the Caregiver in the course of the provision of the Services, the Caregiver agrees to compensate HCA and HCA shall not be held liable for any loss, costs, damages, expense and liability whatsoever in connection with such acts.

Caregiver acknowledges and agrees that in the event of a breach or threatened breach of Section 2, 3, or 4 of this Agreement, HCA shall be entitled, in addition to any other remedies which it may have hereunder or at law or in equity, to a temporary and/or permanent injunction against Caregiver without the necessity of showing actual or threatened damage.

General Provisions

The failure of a Party to enforce at any time or for any period of time the provisions of this Agreement shall not be constructed to be a waiver of such provisions or of the right of such party thereafter to enforce each and every provision.

No changes to this Agreement or any of the provisions hereof, nor any representation, promise or condition relating to this Agreement shall be binding upon HCA unless made in writing and signed on behalf of HCA by a duly authorized officer.

If any provision of this Agreement or part hereof is held by a court of competent jurisdiction to be invalid or unenforceable for any reason, the remainder of the provisions shall remain in full force and effect.

The Agreement will be governed by and construed in accordance with the laws of the Province of Quebec.

This Agreement is drafted in the English language at the request of all parties. Cette convention est rédigée en langue anglaise à la demande des parties.

Present or Last Employer

________________________
Company Name

________________________
Address

________________________
City, Province, Postal Code

________________________
Name and Title of Last Supervisor

________________________
Phone Number | Employment Information
From ________ To ________
          (Mo./Yr.)               (Mo./Yr.)   


Salary
Start _________ Final __________    


Reason for Leaving:
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________ | Your Position and Duties

Position:_____________________ 

Primary Duties: ______________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________

Previous Employer

________________________
Company Name

________________________
Address

________________________
City, Province, Postal Code

________________________
Name and Title of Last Supervisor

________________________
Phone Number | Employment Information
From ________ To ________
          (Mo./Yr.)               (Mo./Yr.)   


Salary
Start _________ Final __________    


Reason for Leaving:
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________ | Your Position and Duties

Position: ___________________

Primary Duties: ______________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________

Assistance in Ambulating | Bed Bath | Feeding Tube | Patient Transferring

Assistance in Bathing | Bed Pan | Hoyer Lift Transfer | Range of Motion Exercise

Assistance in Dressing | Catheter Care | Oxygen Administration | Skin Care

Assistance in Toileting | Colostomy Care | Patient Positioning | Transfer Weight __________

LPN Additional Skills: | Drawing Blood | Injections in Butterflies | Vital Signs

Infection Control | Insulin Injections | Wound/Dressing Changes

Aggression | Dementia: Years? _________ | Incontinence | Post-Surgery Care

Aphasia | Depression | Palliative | Shortness of Breath

Brain Degenerative Disorder | Diabetes | Panic Attacks | Speech Impairment

Cancer | Fractures | Paralyzed | Stroke

Congestive Heart Failure | Hearing Impairment | Parkinson's | Visual Impairment

Cleaning | Cooking | Housekeeping | Laundry

Cleaning Client’s Room & Bath Only | Errands | Ironing | Special Diet

Blood Pressure Kit | Glucose Monitor | Hoyer Lift | Thermometer | Wheel Chair

Gait Belt | Hospital Bed | Oxygen Tank | Walker

HCA Representative | Caregiver

_____________________________________
(Printed Name) | _____________________________________   
(Printed Name)

_____________________________________
(Signature) | _____________________________________
(Signature)

_____________________________________
(Date) | _____________________________________
(Date)